Proximal biceps tenodesis with biceps button

ABSTRACT

Methods and drill guide systems that provide internalization of the biceps tendon with use of fixation devices such as the Arthrex BicepsButton™ or Pectoralis Button tensioned outside a smaller converged drill hole. The technique converges two angled drill holes and use the button to fixate a reinforced (whipstitched) biceps tendon into a single bone versus stabilizing two bones. The biceps tendon is being pulled into the larger of the drilled holes and fixed by the button outside of the smaller drilled hole.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional Application No.60/934, 270, filed Jan. 31, 2014, the entire disclosure of which isincorporated by reference herein.

FIELD OF THE INVENTION

The present invention relates to the field of surgery and, morespecifically, to tendon repairs for reconstructive surgeries.

BACKGROUND OF THE INVENTION

A common type of biceps tendon tear is detachment (partial or complete)of one of the biceps tendons within the shoulder joint. There are twoattachments of the biceps tendon at the shoulder, one within theshoulder joint (the long head of the biceps) and the other in front ofthe shoulder joint (the short head of the biceps). Injuries to theproximal biceps tendon almost always involve the long head of thebiceps. When the long head of the biceps tendon is damaged, a treatmentthat may be considered is biceps tenodesis.

A biceps tenodesis procedure involves cutting the long head of thebiceps just prior to its insertion on the superior labrum and thenanchoring the tendon along its anatomical course more distally along thehumerus. A number of different anchoring techniques are currently usedby surgeons. These techniques include fixation devices such as corticalbuttons, Bio-Tenodesis screws and suture anchors. The key to performinga biceps tenodesis is moving the tendon from its normal attachmentwithin the shoulder joint to a new location further down the humerus. Anoptimal technique would be characterized by limited anterior incisions,early range of motion due to strength and gapping of the repair, andminimum complications.

There is a need for improved methods of attachment of the biceps tendonoutside of the shoulder joint that can cause fewer problems within thejoint. Also needed are methods and devices that allow internalization ofthe biceps tendon with use of fixation devices (such as corticalbuttons) that are tensioned outside a smaller converged drill hole.

SUMMARY OF THE INVENTION

The method of the present invention provides internalization of thebiceps tendon with use of fixation devices such as the ArthrexBicepsButton™ or Pectoralis Button tensioned outside a smaller convergeddrill hole. The technique converges two angled drill holes and use thebutton to fixate a reinforced (whipstitched) biceps tendon into a singlebone versus stabilizing two bones. The biceps tendon is being pulledinto the larger of the drilled holes and fixed by the button outside ofthe smaller drilled hole.

These and other features and advantages of the invention will be moreapparent from the following detailed description that is provided inconnection with the accompanying drawings and illustrated exemplaryembodiments of the invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1-3 illustrate various views of a drill guide system used in themethod of proximal biceps tenodesis of the present invention.

FIGS. 4-19 illustrate subsequent steps of a method of proximal bicepstenodesis of the present invention with the drill guide system of FIG. 1(biceps tenodesis with outrigger and button).

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

In the following detailed description, reference is made to variousspecific embodiments in which the invention may be practiced. Theseembodiments are described with sufficient detail to enable those skilledin the art to practice the invention, and it is to be understood thatother embodiments may be employed, and that structural changes may bemade without departing from the scope of the present invention.

The technique of the present invention improves the biomechanics of theoverall repair and helps overcome surgeons' concerns about rapid returnto ADLs. The technique reliably seats the tendon against the proximalcortex of the bone socket, maximizing the surface area for bone totendon healing. The technique takes advantage of cortical fixation,while providing the unique advantage of minimizing gap formation. Theproximal biceps tenodesis technique restores the anatomical footprintand provides the optimal strength and biomechanical characteristics toallow immediate active range of motion.

The technique converges two angled drill holes and use a fixation device(such as an exemplary biceps or pectoralis button) to fixate areinforced biceps tendon (for example, a sutured or whipstitched bicepstendon) into a single bone versus stabilizing two bones. An exemplaryBicepsButton™ is detailed and described, for example, in U.S. PatentApplication Publication No. 2009/0105754, entitled “Tendon Repair UsingTendon-Slide Technique”, the disclosure of which is incorporated in itsentirety by reference herein. The biceps tendon is being pulled into thelarger of the drilled holes and fixed by the pectoralis button outsideof the smaller drilled hole.

The present invention provides a method of biceps tenodesis by interalia the steps of: (i) exposing a biceps tendon attached to an extremityof a patient; (ii) providing a drill guide system comprising atriangular guide including a plate, a first cannulated tube and a secondcannulated tube, the second cannulated tube being configured to allow acannulated sleeve and drill to pass therethrough, the plate, the firstcannulated tube and the second cannulated tube being integrally attachedto each other and oriented in an overall triangular configuration; (iii)forming a first tunnel or socket; (iv) forming a second tunnel or socketin the humerus with the drill guide system, so that the second tunnel orsocket is spaced apart from the first tunnel or socket and intersectsthe first tunnel to form a resulting humeral intersecting structurehaving a V-shaped configuration; (v) attaching at least one flexiblestrand to the biceps at a biceps region adjacent the first tunnel orsocket; (vi) inserting the biceps in the first tunnel or socket; (vii)pulling the at least one flexible strand attached to the biceps throughand out of the second tunnel or socket; and (viii) securing the at leastone flexible strand with a fixation device (for example, a button) on acortical surface of the humerus.

The present invention provides a method of arthroscopic biceps tenodesisby inter alia the steps of: (i) exposing a biceps tendon attached to anextremity of a patient; (ii) forming a unicortical bone socket (firstsocket) into proximal humerus on which the biceps tendon is attached, atthe inferior border of the bicepital groove; (iii) inserting a firstdrill guide of a triangular guide into the unicortical bone socket; (iv)with the first drill guide remaining in place, forming a second tunnelor socket in the humerus with a second drill guide of the triangularguide, so that the second tunnel or socket is spaced apart from thefirst socket and intersects the first socket to form a resulting humeralintersecting structure, the first and second drill guides beingnon-parallel relative to each other, to allow the resulting humeralintersecting structure to have a V-shaped configuration; (v) attachingat least one flexible strand to the biceps tendon adjacent the firstsocket; (vi) loading the ends of the at least one flexible strandthrough a suture passing device (such as a FiberStick™ suture or nitinolloop, for example) and pulling the ends of the at least one flexiblestrand attached to the biceps through and out of the second tunnel orsocket, to dock the biceps into the first socket; and (vii) securing theends of the at least one flexible strand to the cortical bone surface bytying the ends on top of a BicepsButton™ or pectoralis button.

Referring now to the drawings, FIGS. 1-3 illustrate various views of adrill guide system 30 of the present invention used in a method ofproximal biceps tenodesis to achieve final repair 100 (FIG. 19).

The system 30 includes a triangular guide 10 which includes a plate 10 awith a cannulated tube 15 on the inferior portion and a cannulated tube25 on the superior portion. System 30 also includes a cannulated sleeve26 (adjacent to the superior cannulated tube 25) and a drill 27configured to pass through the cannulated sleeve 26. System 30 alsoincludes a solid rod 16 (adjacent to the inferior cannulated tube)designed to pass through the cannulated tube 15.

Inferior cannulated tube 15 (first drill guide 15 or drill guide #1) andsuperior cannulated tube 25 (second drill guide 25 or drill guide #2)are configured to be non-parallel to each other and to plate 10 a sothat, when viewed from the top, the plate 10 a, inferior tube 15 andsuperior tube 25 form a triangular shape. Preferably, the angles of thetriangular shape formed by the three structures are about 60 degrees.

As shown in FIGS. 2 and 3, the tip of the inferior cannulated tube 15 ofthe triangular guide 10 has a pilot hole 15 a which provides for a drillstop and a method to capture a stiffened suture using the solid rod 16(as detailed below).

An exemplary series of steps of a method of proximal biceps tenodesis ofthe present invention is set forth below. Although, for simplicity, theinvention will be described with reference to biceps tendon, theinvention is not limited to this exemplary only embodiment and hasapplicability to any type of native tendon.

FIG. 4: In an arthroscopic or open fashion, a unicortical socket 91 isformed in bone 90 (proximal humerus 90) at the desired level of thebiceps tenodesis. Proximal humerus 90 is shown with bone socket 91formed at the inferior border of the bicepital groove.

FIG. 5: The inferior cannulated tube end 15 is inserted into thepreviously formed bone socket 91 and the cannulated sleeve 26 is theninserted into the cannulated tube 25 on the superior portion of thetriangular guide 10 as shown.

FIGS. 6 and 7: The drill 27 is inserted into the superior cannulatedsleeve 26 and drilled into the bone 90 forming an intersection bonetunnel 93 to the previously formed uni-cortical bone socket 91. Becauseof the alignment of the inferior and superior tubes 15, 25, bone tunnel93 intersects bone tunnel 91, i.e, the two bone tunnels form a resultinghumeral intersecting structure having a V-shaped configuration.

FIG. 8: A flexible material 60, for example, a stiffened suture 60 suchas Arthrex FiberStick™ or a PDS suture 60 is inserted into the superiorcannulated sleeve 26 and pushed down till it seats into the tip of theinferior cannulated tube 15 within the bone socket 91.

FIG. 9: The solid rod 16 is inserted into the inferior tube 15 of thetriangular guide 10 and fully seated to capture the stiffened suture 60(FiberStick™) or PDS suture 60.

FIG. 10: The entire guide 10 is then removed with the captured stiffenedsuture 60 which will then be used to shuttle the locking stitch suture51 placed in the biceps 50 (as detailed below).

FIG. 11: The stiffened suture 60 has been passed through theintersecting bone tunnels 91, 93 which will then be used to shuttle thelocking stitch suture 51 placed in the biceps 50 (as detailed below).

FIG. 12: A suture passing device 65 is then used to pass at least oneflexible strand 51 (a free suture 51) through the biceps tendon 50creating a stitch region 55 (a locking suture stitch 55).

FIG. 13: Locking stitch 55 is formed in biceps tendon 50 (around thelong head 52) at a position adjacent to the inferior bone socket 91.

FIG. 14: A loop knot 66 is formed in the inferior tail of the stiffenedsuture 60 which was previously passed through the intersecting bonetunnel 91, 93. Both suture ends 51 a, 51 b from the suture 51 of lockingstitch 55 passed through the biceps tendon 50 are placed within the loopknot 66 which is then tightened.

FIG. 15: The superior end of the suture shuttle is pulled to deliver theends 51 a, 51 b of the locking stitch 55 that were previously placed inthe biceps tendon 50.

FIG. 16: The resected biceps 50 with locking stitch 55 is then deliveredinto the inferior bone socket 91 using a shuttle method.

FIG. 17: The end 50 a with locking stitch 55 of the biceps 50 is“docked” into the inferior bone socket 91 with the attached lockingstitch ends exiting the superior bone tunnel 93.

FIG. 18: The two suture ends 51 a, 51 b from the biceps locking stitch55 are placed individually into a fixation device 80, for example, abutton 80 (button implant 80 such as BicepsButton™ 80).

FIG. 19: The button implant 80 is secured against the proximal bonetunnel 93 with locking suture knots 88 formed by suture ends 51 a, 51 b,to achieve final repair 100.

During surgery, to obtain resected biceps 50 with locking stitch 55, thebiceps tendon 50 (attached to an extremity of a patient and to humerus90) may be first exposed and reflected away from the bicipital groovewith a grasper instrument, for example. The long head of the biceps isidentified. The native tendon biceps may be exposed withoutexternalizing the native biceps.

Using suture passing instrument 65, such as a Scorpion Suture Passer,pass at least one flexible strand 51 (for example, suture such as a #2FiberWire® suture) through at least a portion of the biceps 50 adjacentthe bone socket 91 (i.e., in the immediate vicinity of the bone socket91) to form stitched region 55 and tails, ends or limbs 51 a, 51 b ofthe at least one flexible strand 51. Biceps tendon 50 may bewhipstitched arthroscopically with a suture passer instrument such asArthrex Scorpion Suture Passer or similar instrument, to obtainstitched/whipstitched region 55 of the biceps tendon 50. The tendon maythen be cut/resected above the stitched/whipstitched region 55.

As a result of the configuration of the drill guide system 30, the twobone sockets or tunnels 91, 93 are formed in a direction oblique to thebone, i.e., non-perpendicular to the humeral cortex, so that the twobone sockets or tunnels 91, 93 intersect within the bone 90 and form theresulting combined tunnel with a V shape.

The technique of the present invention restores the biceps anatomy tothe humeral side, takes advantage of superior biomechanics, relies onbicortical fixation, and allows immediate postoperative range of motion.

A method of tendon repair of the present invention comprises the stepsof: (i) forming a first bone socket and a second bone socket in a boneadjacent a native tendon, the native tendon being naturally attached tothe bone, the first bone socket being spaced apart from the second bonesocket at a cortical surface of the bone but intersecting with eachother within the bone; (ii) passing a flexible strand around or througha region of the native tendon adjacent the first bone socket; and (iii)passing the flexible strand through the first bone socket, through thesecond bone socket and out of the second bone socket, to insert thenative tendon into the first bone socket. The flexible strand may besecured on the bone cortex by button fixation, for example, or similarfixation techniques. The first bone socket may have a diameter greaterthan the diameter of the second bone socket.

An exemplary method of arthroscopic biceps tenodesis comprises interalia the steps of: (i) forming a unicortical bone socket 91 at theinferior border of the bicepital groove on the proximal humerus; (ii)inserting a first cannulated tube 15 of a drill guide system 30 into theunicortical bone socket 91; (iii) with the first cannulated tuberemaining in place, forming a second tunnel or socket 93 in the humeruswith a second cannulated tube 25, a cannulated sleeve 26 and a drill 27,so that the second tunnel or socket 93 is spaced apart from the firsttunnel or socket 91 and intersects the first tunnel 91 to form aresulting humeral intersecting structure, the first and secondcannulated tubes being non-parallel relative to each other, to allow theresulting humeral intersecting structure to have a V-shapedconfiguration; (iv) attaching at least one flexible strand 51 to abiceps tendon 50 at a region adjacent the unicortical bone socket 91;(v) passing the at least one flexible strand 51 through both the firstand second sockets 91, 93 to insert the biceps tendon into the firstsocket; and (vi) securing the at least one flexible strand 51 to afixation device 80 (for example, a button 80) onto the humeral cortex.

The surgical repairs of the present invention may employ any type offlexible material or suture 60, 51, for example FiberWire® or FiberTape®or FiberChain®. Flexible strand or cord 60, 51 may be made of any knownsuture construct, such as multifilament, braided, knitted, woven suture,or including fibers of ultrahigh molecular weight polyethylene (UHMWPE)or the FiberWire® suture (disclosed in U.S. Pat. No. 6,716,234, thedisclosure of which is hereby incorporated by reference in its entiretyherein). FiberWire® suture is formed of an advanced, high-strength fibermaterial, namely ultrahigh molecular weight polyethylene (UHMWPE), soldunder the tradenames Spectra (Honeywell) and Dyneema (DSM), braided withat least one other fiber, natural or synthetic, to form lengths ofsuture material. The preferred FiberWire® suture includes a core withina hollow braided construct, the core being a twisted yarn of UHMWPE.

The flexible strand 51 may be also in the form of flat suture tape (forexample, a collagen stuffed suture tape or a high strength suture tape,such as disclosed in U.S. Pat. No. 7,892,256) or a combination of sutureand tape, a stiff material, or combination of stiff and flexiblematerials, depending on the intended application. The flexible strand 51may be also in the form of a suture chain described in U.S. Pat. No.7,803,173 and/or in U.S. Patent Appl. Publ. No. 2007/0135843, thedisclosures of both of which are incorporated by reference in theirentirety herewith. The strands 51 may also be formed of a stiffmaterial, or combination of stiff and flexible materials, depending onthe intended application. The strands may be also coated and/or providedin different colors.

Although the present invention has been described in connection withpreferred embodiments, many modifications and variations will becomeapparent to those skilled in the art. While preferred embodiments of theinvention have been described and illustrated above, it should beunderstood that these are exemplary of the invention and are not to beconsidered as limiting. Accordingly, it is not intended that the presentinvention be limited to the illustrated embodiments, but only by theappended claims.

What is claimed as new and desired to be protected by Letters Patent ofthe United States is:
 1. A method of tendon repair, comprising the stepsof: forming a first bone socket and a second bone socket in a boneadjacent a native tendon, the native tendon being naturally attached tothe bone, the first bone socket being spaced apart from the second bonesocket at a cortical surface of the bone but intersecting with eachother within the bone; passing a flexible strand around or through aregion of the native tendon adjacent the first bone socket; and passingthe flexible strand through the first bone socket, through the secondbone socket and out of the second bone socket, to insert the nativetendon into the first bone socket.
 2. The method of claim 1 furthercomprising the steps of: inserting a first cannulated tube of atriangular guide into the first bone socket, the triangular guideincluding a plate, the first cannulated tube and a second cannulatedtube, the first and second cannulated tubes being non-parallel to eachother and to the plate; and forming the second bone socket with thesecond cannulated tube and a drill, the second bone socket intersectingthe first bone socket and forming a resulting bone tunnel having a Vshape.
 3. The method of claim 2 further comprising the steps of: passingtails of the flexible strand through the second bone socket of theresulting bone tunnel with the V shape; and securing the tails of theflexible strand to a fixation device onto the cortical surface of thebone and over the second bone socket.
 4. The method of claim 3, furthercomprising the steps of tying the tails of the flexible strand over thefixation device.
 5. The method of claim 3, wherein the fixation deviceis a button.
 6. The method of claim 3, further comprising the step ofattaching the tails of the flexible strand to a suture passer andpassing the tails through and out of the second socket.
 7. The method ofclaim 6, wherein the suture passer is a loop of a stiffened suture. 8.The method of claim 6, wherein the suture passer is a nitinol loop. 9.The method of claim 1, wherein the first bone socket has a diameterlarger than a diameter of the second bone socket.
 10. The method ofclaim 1, wherein the native tendon is biceps.
 11. The method of claim 1,wherein the flexible strand is suture, suture tape or suture chain. 12.The method of claim 1, wherein the flexible strand is formed of suturematerial comprising ultrahigh molecular weight polyethylene.
 13. Amethod of proximal biceps tenodesis, the method comprising the steps of:exposing a native biceps without externalizing the native biceps;forming a first socket in proximal humerus, at an inferior border ofbicepital groove; inserting a first cannulated tube of a drill guidesystem into the first bone socket, the drill guide system including atriangular guide having a plate, the first cannulated tube and a secondcannulated tube, the first and second cannulated tubes beingnon-parallel to each other and to the plate, the drill guide systemfurther including a solid rod, a cannulated sleeve and a drill; whilethe first cannulated tube remains in place, forming a second bone socketwith the second cannulated tube, the cannulated sleeve and the drill,the second bone socket intersecting the first bone socket and forming aresulting bone tunnel having a V shape; passing a first flexible strandthrough the first socket and the second socket of the resulting bonetunnel having the V shape; passing a second flexible strand around orthrough the native biceps adjacent the first bone socket to form atleast one locking stitch and two free ends; employing the first flexiblestrand, passing the two free ends of the second flexible strand throughthe first and second bone sockets, and out of the second bone socket;pulling on the two free ends to insert the native biceps into the firstsocket of the resulting bone tunnel with the V shape; and passing thetwo free ends through apertures of a button and tying the two free endsover the button and on humeral cortex, to secure the native biceps intothe resulting bone tunnel having the V shape.
 14. The method of claim13, wherein the first and second cannulated tubes are integral to theplate and form an angle of about 60 degrees relative to the plate and toeach other.